<Home> <Muslim Scientists> <Al-Zahrawi> <The most famous surgeon the Middle EAst>

Dr. Simon Hayek
SPAIN

• SURGERY IN THE WEST
  
• Treatment of liquid accumulation in babies' heads.
  
• REFERENCES

The Arabs have contributed in an essential manner to the different fields of Science and Civilization. If we mention arithmetics and algebra a good example is al-Khawarizmi, in optics Ibn al-Haytham, in medicine al-Razi, Ibn Sina, Ibn Rushd and al-Zahrawi, in philosophy al-Kindi, al-Farabi and Ibn Tufail, and others from other fields of knowledge like al-Bairooni, al-Zarkali, Ibn Wafid al-Ghafiqi, al-Majriti, and so on.

We are here for a Convention on Islamic Medicine in the Middle Ages, and more precisely on a specific branch of Medicine: surgery, represented by the most famous surgeon of the Middle Ages, without any doubt, Abul Qasim al-Zahrawi.

AI-Zahrawi lived between the end of the Xth century A.C. and the beginning of the Xlth., in the town of al-Zahra built by Abdel Rahman al-Nasser a few miles away from Cordoba, the Ommeyad capital of al-Andalus. He was the Physician of al-Hakam II, called al-Montassir, and lived during the reigns of Hisham al-Moayyed and Mansour Ibn Abou Amer and he probably died in 1013 A.C.

However, the question of the exact date of his death is not the main issue here as we are more interested in his great book, or more exactly his encyclopedia of medicine entitled, "Hints for those who are not able to invent".

This encyclopedia is made up of 30 books, the last one exclusively on surgery , as if he wanted to show the doctors or the ones who intended to practice medicine, that you first have to study all the branches of medicine very deeply before you are able to be a fairly good surgeon.

I have based my study on a manuscript of the Monastery of el-Escorial, about 50 Kilometers north of Madrid, the capital of Spain.

Here are some Chapters of said documents:
CHAPTER 1. -Treatment of liquid accumulation in babies' heads.
CHAPTER 2. -Section of two arteries located behind the ears and called
CHAPTER 3. -Extraction of temple arteries.
CHAPTER 4. -Treatment of continuous and constant lachrymal flow.
CHAPTER 6. -Treatment of what falls into the ear.
CHAPTER 7. -Treatment of ear obstruction.
CHAPTER 10. -Treatment of tearing of the upper eyelid.
CHAPTER 1 9. -Cauterization of a fistula in the mouth.
CHAPTER 20. -Cauterization of loose teeth and gums.
CHAPTER 22. -Cauterization of a scrofula due to phlegms and colds.
CHAPTER 25. -Cauterization of axillae.
CHAPTER 27. -Cauterization of cold liver.
CHAPTER 29. -Cauterization of convulsions.
                      (Convulsion and inflammation of the nerve)
CHAPTER 30. -Cauterization of the spleen.
CHAPTER 31. -Cauterization of Hydropsy.
CHAPTER 32. -Cauterization of legs and feet.
CHAPTER 33. -Cauterization diarrhea.
CHAPTER 34. -Cauterization of hemorrhoids.
CHAPTER 35. -Cauterization of warts after cutting them off.
CHAPTER 38. -Extraction of a leech appearing in the throat.
CHAPTER 39. -About opening and cutting tumors.
CHAPTER 40. -Cauterization of the hip.
CHAPTER 41. -Cauterization of the sciatica nerve.
CHAPTER 42. -Cauterization of back pains.
CHAPTER 43. -Cauterization of the starting burns.
CHAPTER 44. -Cauterization of the gout and the pain in the joints.
CHAPTER 45. -Cauterization of herniae.
CHAPTER 46. -Cauterization of Elephantiasis.
CHAPTER 47. -Cauterization of Anesthesia.
CHAPTER 48. -Cauterization of Leprosy.
CHAPTER 49. -Cauterization of Cancer.

In this chapter al-Zahrawi says:

When cancer is at its start and you want to stop it, you should cauterize it with a circular plate all around it. Some doctors say it should be deeply cauterized in the center, but I do not agree with this opinion. The correct procedure is to cauterize in a circle or to do it in small subsequent cauterizations all around.
CHAPTER 50. -Cauterization of colics.
CHAPTER 51. -Cauterization of gangrene.
CHAPTER 52. -Cauterization of ingrown corns and others.
CHAPTER 53. -Cauterization in cases of shivers.
CHAPTER 54. -Cauterization of pustules.
CHAPTER 55. -Cauterization of hemorrhage resulting from the sectioning of arteries.

Some people have criticized al-Zahrawi because he used cauterization too much. However, this is not correct as he followed the principle according to which: "the last remedy is cauterization". Thus he used it when all other means had failed to cure the patient.

Let us now examine Section II of Book 30 of the medical encyclopedia of al-Zahrawi in which he describes incisions, puncturing, bloodletting and surgery.

CHAPTER 54. -Treatment of children born without a urinary orifice, or when the orifice is too narrow or misplaced.
CHAPTER 55. -About pimples appearing on the prepuce.

CHAPTER 56. -On boy's circumcision and errors derived from it.
  CHAPTER 57. -Treatment of urine retention in the bladder.
  CHAPTER 58. -Injection of the bladder and picture of adequate instruments for this purpose.
  CHAPTER 59. -Extraction of gallstones.
  CHAPTER 60. -Extraction of Gallstone in women.

He was the first one to dedicate a chapter to this matter, and it might be interesting to give a look to his exposition as he says:

Very few women have gallstones. In case one does she must be treated which is difficult for many reasons: one of them is that a woman would not show herself to a doctor if she is decent or depends on the honor of a doctor, the second is that she may be a virgin, the third one is that there is no woman expert in this matter available, especially in hand operation, and the fourth is that the incision for the gallstones in women is performed far from the place of the stones and is an indecent one which is dangerous; and if needed, it requires an expert woman physician, and this is difficult to find. So if you do not find her, get a decent and benevolent physician and let the woman be accompanied by a woman introduced in woman matters or in some way familiar with them, and instruct her to do everything she is told to find the gallstone first of all. And you should find out whether the woman is a virgin, in such case she should enter a finger in her buttocks and locate the stone. If she does, and presses it with her finger then, instruct her to cut on it. If she is not a virgin or is a widow, instruct the assistant to enter her finger in the patient's genitals and search for the stone after putting her left hand on the bladder squeezing it thoroughly. If she finds it she should push it away from the entrance of the bladder and let it go down until she locates it again at the origin of the thigh, and make a cut towards the middle of the vagina at the origin of the leg in any direction which is convenient or in which she has located the stone, without relieving the pressure of her finger under the stone. The cut should first be small and she should enter the instrument in this small incision, then if she finds the stone she should enlarge it to allow the stone to come out.

You should know that there are many kinds of stones: small and large, smooth and rough, long and round or problematic. Know all about the different kinds of them to find out how to treat them and in case you have trouble stopping a hemorrhage, powder the wound with sulphate and hold it for one hour until the flow has stopped, then go back to work until you extract the stone.

Provide yourself with the instruments mentioned for the extraction of stones in men and use them in your work. And if you have to face a hemorrhage and you deduce from the pulsation it is due to the cut of an artery, put powder on the wound and tie it with bandages and leave it, do not treat it, and leave the stone, do not extract it as the patient might die. Then heal the wound and if the blood flow diminishes after some days and the wound decays, get back to your work until you extract the stone, with God's will.

CHAPTER 82. -On the instruments used for the injection in the anal diseases, diarrhea and colics.
 Different Surgeries: For a stone strike, sword or knife cut, arrow or lance wound on the head, neck, chest, abdomen or liver.
Hand Operation and Surgery: AI-Zahrawi says: Hand operation is not currently practiced and has almost disappeared, however we still have some simple drawings in the primitive books that became scattered and subject to errors and confusion which makes their meanings difficult to understand and lessens their utility.

He also says somewhere else: This art has disappeared as I do not find it useful at all and this is due to the fact that the art of medicine is lengthy and one should first practice anatomy as it was established by Galen.

This is what al-Zahrawi says about the state of surgery in the Islamic world, or at least in his country, al-Andalus. In the Christian world we can say it was totally unexisting in the Xth. century A.C. and this activity did not start until XIVth century. This is when surgery encyclopedias appeared after the Western countries discovered the books of Galen, Hypocrate, Ibn Sina, al-Razi and other renowned doc- tors whose works were transmitted to them as we shall see.

Abul Qasim al-Zahrawi reached the West through translation made into Latin in Toledo by Gerardo de Cremona.

Gerardo was born in Cremona in the Italian region of Lombardia and was very fond of science in his childhood. He tried to find the book of Ptolemy "The Almagest" without success, and he was told he could find it in Toledo.

At that time, that is during the first half of the Xlth. century, Toledo, in the heart of al-Andalus, had been conquered peacefully by al-Fonso VI, King of Castille, in 1085 and was the meeting point of the three revealed religions: Islam, Christianism and Judaism.

It also gathered a huge collection of scientific manuscripts brought from Cordoba after the destruction of Madina al-Zahra and the looting of the library of al-Hakam al-Muntessir that includes 400,000 volumes. A great portion of these volumes were taken to Toledo in the first half of the Xlth. century.

Al-Fonso VI of Castille, after his conquest of Toledo, was not able to erase the Arabic traits of the city; the Arab language was still used for centuries after that and coins with Arab inscriptions were, minted and used for trade between Christians and Muslims up to the XIVth. century and even after that.

As we said; Gerardo de Cremona arrived in Toledo in search of the "Almagest" and he found it and translated it into Latin with the help of some Arabists.

The translation from Arabic to Latin, which was the prevailing language at that time, was carried out as follows: The translators coming from Toledo knew Latin and not Arabic, while the Cordovans who were generally Arabs or hebrews spoke Arabic or the colloquial language (Roman) but not Latin. The latter would read the Arabic text in the colloquial language and the translators would put it in Latin. This is how most of the Greek books translated into Arabic and also the original Arabic books written by Arab philosophers, scientists and physicians were translated.

Gerardo de Cremona was not the only one to translate Arabic books into Latin. Many others came from all over Europe to translate the Arabic and Greek texts written in Arabic, into Latin because they were not able to reach the original Greek books directly, for reasons which are not within the scope of this work, and had to use Arabic as an intermediary language.

The translation from Greek to Latin directly did not take place until the second half of the Xllth. century. However, by that time, the original Arabic books and the Greek books translated into Arabic had " already been put in Latin and had been of great profit to Occidental scientists.

This introduction was necessary to explain the way in which the Arabic culture was made available to the Occidental.

Let us now go back to Gerardo de Cremona. He was one of many translators who came to Toledo in search of science in the Xllth. century A.C. Gerardo de Cremona was astonished to see the amount of knowledge of all kinds gathered in Toledo, so he learned Arabic until he knew it thoroughly and was able to translate Arabic sciences without any help or just with some counselling when a matter was too difficult. This is how he translated over 60 books of all branches of science before he died in Toledo in 1187.

One of the books he translated was "Hand Operation or Surgery" which is the 30th book of the medical encyclopedia of al-Zahrawi. The title of this book in Latin was: 'Uber Azaragui de Cirurgia' and it was printed for the first time in Venice in 1497 A.C.

In 1471 the 28th book of al-Zahrawi's encyclopedia, which is a treaty on the composition of drugs, was published in Venice. Its Latin title was: 'Uber Servidoris Sive Uber XXVIII Bulchasim Benabaceerin, Interprete Simone Januensi et Abraham Judeo'. This edition was translated into Spanish by Al-Fonso Rodriguez de Tudela and printed in Valladolid in 1516.

The theoretical section of al-Zahrawi's encyclopedia was published by Sigmund Grimm under the title: 'Uber Theoricae nec non Practicae Alsaharavii' and was printed in Augsburg in 1519.

The section on gynaecology was printed by Gaspar Wolf in Basel in 1566 under the title: 'De Gyanciis'. Another edition was also published in Basel 1541 and its title was: ' Abulcasis Methodus Mdendi cum Instrumentis ad Emres fere Morbo de Pictis'.

The last edition of the surgery treaty of Abul Qasim al-Zahrawi with a bilingual Arabic/Latin text appeared in London in 1178.

Aldo Mielli says it is difficult to translate title of the book and he thinks the best translation is the following: 'Concessio ei data qui componere haud valet'.

This book has also been partially translated from Latin to Provencal and then into hebrew and there is no full translation of either the text or the translation, only many partial editions.

Also the surgery section which is Book 30, was published as part of a book written by De Chauliao and printed in Venice in 1497 under the title: 'Chirurgia Parva'.

SURGERY IN THE WEST

Surgery started to develop in the West with a book written by Roger Salerno and entitled 'Practica Chirurgica'. This book was published at the end of the Xllth century, that is after the publication of the translation of 'Hand Operation' by Gerardo de Cremona.

In his book 'Science in the Middle Age'2 Crombie says that Roger owes the Bysantine physicians more than he owes the Arab physicians. I do not know how accurate this opinion is as all the sciences, hellenic and others, reached the West through the Arabs, and Roger Salerno treated the diseases according to the Arabic way that is by means of ointments, powders, bandages, rags and straps especially in cases of hemorrhage.

After that, in the beginning of the Xlllth century Rolando di Parma demonstrated great experience in the treatment of head wounds and skull fractures, and he advised the need of cleaning the hands before carrying out operations and warming the patient during the surgery.

Those physicians treated the ulcers according to Galen's instructions as they left the wound suppurate and then used grease and ointments to heal it. And this is what al-Zahrawi did 300 years before them.

Guy de Chauliac (1300-1367) was the first of a long series of French surgeons influenced by al-Zahrawi. He studied in Boulogne, France, taught in Montpellier and then joined the Pop's Court in Avignon. He wrote a book: 'La Pratique en Chirurgie' printed in Lyon in 1478. As for the original Latin version, it was printed in Venice in 1490 and had great influence on the subsequent surgeons as it advised to stop using insecticides and to return to the use of ointments oils and lints following in this way the steps of al-Zahrawi.

We can also mention an Italian surgeon: Guillermo di Saliceto who lived in the Xlllth century and was the first to be influenced by al-Zahrawi in the treatment of a disease that affects babies and which is called Hydrocephalus. The Italian surgeon says the treatment consists of making a simple hole in the head by means of cauterization to extract the liquid.

Let us now find out what al-Zahrawi says about this disease which he calls; 'Concentration of liquid in babies' heads' in Chapter 1 of Book 30 of his encyclopedia.

Treatment of liquid accumulation in babies' heads.

This disease occurs frequently to babies at birth if the midwife presses violently on the child's head, or can also be caused by some unknown defect which I have never seen in anyone but babies and the ones I have seen affected by it died very promptly. So I stopped intervening in it. I have seen children with their heads full of liquid and growing every day in such way that they cannot sit up any more because of the size of their head, and the liquid keeps increasing until they die.

This humor may appear between the skin and the bone or under the bone on the brain. When the liquid is between skin and bone and the tumor is small you should make only one incision of about two knots in the middle of the head and transversally and let the liquid flow out. And this is the sharp end of the scalpel (picture).

When the accumulation of liquid and the tumor are larger, make two crossed incisions in this way. If the liquid is under the bone and this is shown by the fact that the skull sutures are open in all directions and the liquid diminishes if you press it with your hand, you should make three incisions in the center of the head in this way. After making the incisions extract all the liquid then fill the cuts with rags and cover them with ointments and oil until the fifth day. Then undo the bandage, heal the wounds with lints and ointments and put the head into place. The patient should be fed all kind of dry food low in moistness until head is cured with God's will.

Another characteristic of the incision is that you should locate the place of the liquid accumulation as it could either be more towards the back or the front or the right or left. Thus, you should direct the incision towards the place where the tumor has appeared, within possible reach, making sure no artery may be cut, as the patient could die from a hemorrhage taking place simultaneously with the flow of the liquid.

In the above mentioned book Crombie says the Middle Ages surgeons like Mondino de Luzzi (1275-1326), for example, gave very good descriptions of hernia operations. I haven't read the description of this surgeon but I don't think it al-Zahrawi's description of this kind of operations.

The Arab physician al-Zahrawi, in chapter 45 of Book 30 of his encyclopedia, entitled 'Cauterization of Hernias' says:

If an inguinal hernia appears and a portion of intestines or grease springs up towards the testicles, you should instruct the patient to stop eating immediately and to take laxatives to empty his intestines from excrements.

Let him lay down on his back and instruct him to hold himself until the hernia springs up. Then push it back with your finger and make a mark under it and on the pubic bone in the shape of a semi-circle with its ends heading towards the upper part of the body. Heat a cauterizing instrument with the same shape until it becomes white and sparkles and push the hernia in and let a servant put his hand on the place to prevent it from springing out and let the patient open his legs apart and put a cushion under him. Let another servant sit on his legs and another one sit on his chest and hold hands. Apply the cauterizing instrument on the pubis itself and hold it there until it reaches the bone and if it does not apply it again. While you are cauterizing prevent the intestines from springing out with your hand because if you burn it, it could cause the patient's death or an immense prejudice.

You should know that your work will not succeed unless you reach the bone. For the children use a milder and more adapted instrument, as well as in the case of adults you should use an adequate one.

After three days apply grease on the wound until the burning marks disappear, then treat it with ointments until it is cured. The patient should remain on his back forty days until the wound heals. He should eat laxative food during his convalescence to avoid a reproduction of the hernia when defecating.

If he wants to stand up after forty days, he should use a bandage for another forty days and avoid tiring himself, eating or drinking too much and screaming. If he follows these instructions he will be totally cured with God's will.

And al-Zahrawi says: I shall talk about the treatment of hernias with an incision in the corresponding chapter .

As for the hernia appearing in the rest of the abdomen, when it is at its start and you don't want it to become worse, cauterize it with a round instrument of an adequate size as it should burn only two thirds of it. Then treat it in the described way and it shall not increase with God's help.

This was al-Zahrawi only mentioned in three lines in Abi Usabiaa's book 'Prominent Comments on Doctors' Categories', while the Occidentals have dedicated lengthy comments to him and detailed explanations to his work, after translating it into Latin in the Middle Ages, and have followed his principles until the 17th century and even after that.

Credit to him was justly given.

REFERENCES
1- LECLERC: Histoire de ma dedecine arabe, Paris 1876 vol, I, pgs. 437-457
2 -A.C. CROMBIE: Historia de la ciencia de San Augustin a Galileo, PP. 212 -215, Alianza Editorial- Madrid 1974.
3 -A.G. PALENCIA: Don Raimundo arzobispo de Toledo (Col. Labor.)
4 -JUAN VERNET: La Cultura Hispano arabe en Oriente Y Occidente. Ariel Historia, Barcelona 1978.
5- SANCHEZ PEREZ: La Ciencia arabe en la Edad Media. Instituto de estuding africanos, 1954.
6 -A.C. CROMBIE: Histoire des la Ciencia de San Augustin a Galileo Alianza Universidad, Madrid 197.
7 -DR. JOSEF LOBEL: Historia sucienta de la Medicina Mundial. Espaza Calpa Buenos Aires, Mexico 1950.
8- ALDO MElLI: Panorama general de Historia de la Ciencia. Espaza Calpe Argentina 1952.